Provider Demographics
NPI:1902602303
Name:THOMAS, AMANDA GAIL
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAIL
Last Name:THOMAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 OAKLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3068
Mailing Address - Country:US
Mailing Address - Phone:601-288-3441
Mailing Address - Fax:601-288-3460
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:601-288-3441
Practice Address - Fax:601-288-3460
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907252363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty